Homeless Student Grievance Form

Policy Code: 
Adoption Date: 
Tuesday, October 24th, 2006
Review Date: 
Tuesday, September 28th, 2010



Name of School:_________________________________________________________


Name of Student:_________________________________________________________

                                    Last                                    First                                                Middle


Birth Date:_____/_____/____  Age:______  Grade:______  Gender:     Male      Female


This information is intended to address the McKinney-Vento Act U.S.C. 11431.  The answers to this information help to determine the services this student may be eligible to receive.  When a dispute arises, the following procedure will be followed:

1.  The child or youth has been immediately admitted to the school

in which enrollment is sought, pending resolution of the dispute.            Yes      No

2.  The parents or guardian of the youth are provided with a written

explanation of the school’s decision regarding school selection

and enrollment, including the right to appeal the decision.                       Yes      No 

3.  The child, youth, parent, or guardian has been referred to the

Iron County School District Homeless Liaison for implementation

of the dispute.                                                                                          Yes      No

4.  If the homeless student is an unaccompanied minor, the youth has

been immediately enrolled in school pending resolution of the dispute.      Yes      No

Please complete the remainder of this form.

Please describe the nature of the complaint.  Please include the names and ages of the children involved and the nature of the name(s) of school personnel involved.



Name of parent(s)/guardian:__________________________________________________


Address:______________________________________  Phone:_____________________


Signature:_____________________________________  Date:______________________


Relationship to Student:_____________________________________________________



Non-Discrimination Statement

Iron County School District is committed to a policy of equal employment opportunity and does not discriminate in the terms, conditions, or privileges of employment on account of race, age, color, sex, national origin, physical or mental disability, or religion or otherwise as may be prohibited by federal and state law.

School District Office

Hours 8 a.m. - 5 p.m. Mon.- Fri.
2077 W. Royal Hunte Dr.
Cedar City, Utah 84720
PH 435.586.2804  FAX 435.586.2815